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Eligibility

Oystehr provides realtime insurance eligibility checks. Submit a patient's insurance information and receive a response detailing the patient's coverage and benefits.

Making an Eligibility Check Request

You can perform an eligibility check with either the Typescript SDK or the API:

Perform an eligibility check with the SDK:

zapehr.project.rcm.eligibilityCheck({
  eligibilityRequestId: "7cb4321f-8d52-4d27-93ba-f20c86cbceaf",
})

The UUID value for eligibilityRequestId provides a reference to a specific FHIR CoverageEligibilityRequest resource. All values that will be used in the eligibility check will be pulled from this resource and other FHIR resources that it references. See the eligibility FHIR property charts below for additional details.

There are five entities at play in an eligibility request:

Patient: person receiving care
Subscriber: person the insurance policy is under
Coverage: information about the insurance policy
Provider: practitioner expected to perform the care
Payer: insurer

note: in some cases, the patient and subscriber may be the same person

Access Policy

To place an eligibility check, your user needs to have the following access policy:

{
  "rule": [
    {
      "action": "RCM:InsuranceEligibility",
      "resource": "RCM:CheckInsuranceEligibility",
    },
  ],
}

Eligibility Response

The eligibility response will come in the form of a FHIR CoverageEligibilityResponse.

Benefits

The key information used to understand whether a Patient has active coverage of the appropriate type for the services you're providing is found in CoverageEligibilityResponse.insurance.item (opens in a new tab). This property holds an array of benefits provided by the payer. These benefits are coded following the X12 service type codes (opens in a new tab) standard.

Examples of CoverageEligibilityResponse.insurance.item (opens in a new tab):

These two examples show a benefit with a service type code of 30. This code is defined in the coding standard (opens in a new tab) as:

Plan coverage and general benefits for the member's policy or contract.

For many use cases, 30 is the only code you are looking for to determine whether the patient is covered for your services.

Deductible

{
    "category": {
        "coding": [
            {
                "code": "30",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit"
            }
        ],
        "text": "Health Benefit Plan Coverage"
    },
    "unit": {
        "coding": [
            {
                "code": "FAM",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit-level"
            }
        ],
        "text": "Family"
    },
    "term": {
        "coding": [
            {
                "code": "24",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit-period"
            }
        ],
        "text": "Year to Date"
    },
    "network": {
        "coding": [
            {
                "code": "W",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-inplan-network"
            }
        ]
    },
    "benefit": [
        {
            "type": {
                "coding": [
                    {
                        "code": "C",
                        "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit-coverage"
                    }
                ],
                "text": "Deductible"
            },
            "allowedString": "0"
        }
    ]
}

Out of Pocket Maximum

{
    "category": {
        "coding": [
            {
                "code": "30",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit"
            }
        ],
        "text": "Health Benefit Plan Coverage"
    },
    "unit": {
        "coding": [
            {
                "code": "FAM",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit-level"
            }
        ],
        "text": "Family"
    },
    "term": {
        "coding": [
            {
                "code": "24",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit-period"
            }
        ],
        "text": "Year to Date"
    },
    "network": {
        "coding": [
            {
                "code": "W",
                "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-inplan-network"
            }
        ]
    },
    "benefit": [
        {
            "type": {
                "coding": [
                    {
                        "code": "G",
                        "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-benefit-coverage"
                    }
                ],
                "text": "Out of Pocket (Stop Loss)"
            },
            "allowedString": "0"
        }
    ],
    "extension": [
        {
            "url": "https://extensions.fhir.oystehr.com/eligibility-insurance-type",
            "valueCodeableConcept": {
                "coding": [
                    {
                        "code": "C1",
                        "system": "https://terminology.fhir.oystehr.com/CodeSystem/eligibility-insurance-type"
                    }
                ],
                "text": "Commercial"
            }
        }
    ]
}

FHIR Resources

Before placing the eligibility check request, ensure that these FHIR resources are created and up to date.

Eligibility Request (CoverageEligibilityRequest)

The CoverageEligibilityRequest resource will be referenced in the eligibility check request, and this resource will in turn reference other FHIR resources.

JSON Path	Description
`patient`	Reference to patient resource
`provider`	Reference to provider resource
`insurance[0].coverage`	Reference to insurance coverage
`servicedDate`	Date when the healthcare service would be rendered
`item.category`	Determines the eligibility benefits in response (default is 30)
`item.productOrService	Determines the eligibility for a particular procedure

{
  "id": "92755430-5ea0-4927-a74d-5e3425efd9b4",
  "resourceType": "CoverageEligibilityRequest",
  "status": "active",
  "purpose": [
    "benefits"
  ],
  "created": "2024-06-13",
  "patient": {
    "reference": "Patient/a5841e0d-8270-49ff-87e0-96520c283639"
  },
  "insurer": {
    "reference": "Organization/0d03d037-af76-4813-b228-105336238317"
  },
  "provider": {
    "reference": "Organization/bea1bda2-e069-4f91-ac50-be5c8f1337b2"
  },
  "insurance": [
    {
      "coverage": {
        "reference": "Coverage/755a526a-0c78-4731-bac2-d6209fc30f36"
      }
    }
  ],
  "item": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.oystehr.com/CodeSystem/benefit-category",
            "code": "30",
          },
        ],
      },
      {
        "productOrService": {
          "coding": [
            {
              "system": "http://terminology.oystehr.com/CodeSystem/product-code",
              "code": "99213"
            }
          ]
        }
      }
    },
  ],
  "meta": {
    "versionId": "6dbae679-6800-4ee9-8726-c34a60ca34ef",
    "lastUpdated": "2024-07-18T13:21:53.649Z"
  }
}

Patient (Patient)

JSON Path	Description
`name[0].family`	Last name of patient
`name[0].given[0]`	First name of patient
`name[0].given[1]`	Middle name of patient
`birthDate`	Dob of patient
`gender`	Gender of patient

{
  "id": "a5841e0d-8270-49ff-87e0-96520c283639",
  "meta": {
    "versionId": "27ea83d9-adc4-441f-ba7c-43b32eb25a92",
    "lastUpdated": "2024-07-01T17:00:46.690Z"
  },
  "name": [
    {
      "given": [
        "PETER"
      ],
      "family": "GRIFFIN"
    }
  ],
  "gender": "female",
  "address": [
    {
      "city": "QUAHOG",
      "line": [
        "31 SPOONER ST"
      ],
      "state": "RI",
      "postalCode": "11738"
    }
  ],
  "birthDate": "2022-05-14",
  "resourceType": "Patient"
}

Subscriber (Patient | RelatedPerson)

JSON Path	Description
`name[0].family`	Last name on insurance card
`name[0].given[0]`	First name on insurance card
`name[0].given[1]`	Middle name on insurance card
`birthDate`	Dob of person on insurance card
`gender`	Gender of person on insurance card

{
  "id": "a5841e0d-8270-49ff-87e0-96520c283639",
  "meta": {
    "versionId": "27ea83d9-adc4-441f-ba7c-43b32eb25a92",
    "lastUpdated": "2024-07-01T17:00:46.690Z"
  },
  "name": [
    {
      "given": [
        "PETER"
      ],
      "family": "GRIFFIN"
    }
  ],
  "gender": "female",
  "address": [
    {
      "city": "QUAHOG",
      "line": [
        "31 SPOONER ST"
      ],
      "state": "RI",
      "postalCode": "11738"
    }
  ],
  "birthDate": "2022-05-14",
  "resourceType": "Patient"
}

Payer (Organization)

JSON Path	Description
`identifier.value` for `identifier` with `type` of value `XX` and `code` `http://terminology.hl7.org/CodeSystem/v2-0203`	Insurance company identifier (Payer ID)

{
  "resourceType": "Organization",
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "code": "XX",
            "system": "http://terminology.hl7.org/CodeSystem/v2-0203"
          }
        ]
      },
      "value": "00803"
    }
  ],
  "name": "NY BCBS - EMPIRE",
  "id": "0d03d037-af76-4813-b228-105336238317",
  "meta": {
    "versionId": "cd116228-fcea-427e-9634-ddc6f8a77d6d",
    "lastUpdated": "2024-07-01T17:01:17.424Z"
  }
}

Provider (Practitioner | PractitionerRole | Organization)

JSON Path	Description
`identifier.value` for `identifier` with `type` of value `NPI` and `system` `http://terminology.hl7.org/CodeSystem/v2-0203`	NPI for provider who will be providing the care
`name[0].family`	Last name for provider who will be providing the care
`name[0].given[0]`	First name for provider who will be providing the care
`identifier.value` for `identifier` with `system` `http://nucc.org/provider-taxonomy`	Taxonomy for provider who will be providing the care
`identifier.value` for `identifier` with `code` ('SS' or 'NE') and `system` `http://terminology.hl7.org/CodeSystem/v2-0203`	Tax ID for provider who will be providing the care
`'S' if identifier.value exists for identifier with code 'SS' and system http://terminology.hl7.org/CodeSystem/v2-0203 otherwise 'E'`	Tax ID type for provider who will be providing the care
`address[0].line[0]`	Address line 1 for provider who will be providing the care
`address[0].city`	Address city for provider who will be providing the care
`address[0].state`	Address state for provider who will be providing the care
`address[0].postalCode`	Address postal code for provider who will be providing the care

{
  "id": "bea1bda2-e069-4f91-ac50-be5c8f1337b2",
  "resourceType": "Organization",
  "name": "New York Care",
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "code": "NPI",
            "system": "http://terminology.hl7.org/CodeSystem/v2-0203"
          }
        ]
      },
      "system": "http://hl7.org/fhir/sid/us-npi",
      "value": "1790914042"
    },
    {
      "type": {
        "coding": [
          {
            "code": "NE",
            "system": "http://terminology.hl7.org/CodeSystem/v2-0203"
          }
        ]
      },
      "value": "270309905"
    }
  ],
  "address": [
    {
      "line": [
        "16 SOME STR"
      ],
      "city": "NEW YORK",
      "state": "NY",
      "postalCode": "10087"
    }
  ],
  "telecom": [
    {
      "system": "phone",
      "value": "5168690650"
    }
  ],
  "meta": {
    "versionId": "01a7b180-7cb2-44a9-9f5e-e621440a167d",
    "lastUpdated": "2024-07-18T13:25:38.705Z"
  }
}

Note: in the case of placing an eligibility check against a provider group, rather than an individual, use the last name field for the provider group name.

Insurance Policy Information (Coverage)

JSON Path	Description
`payor[0]`	Reference to payer organization
`subscriberId`	Subscriber's member ID
`relationship`	Relationship of patient to the person on insurance card (self

{
  "resourceType": "Coverage",
  "beneficiary": {
    "reference": "Patient/a5841e0d-8270-49ff-87e0-96520c283639"
  },
  "payor": [
    {
      "reference": "Organization/0d03d037-af76-4813-b228-105336238317"
    }
  ],
  "status": "active",
  "subscriber": {
    "reference": "Patient/a5841e0d-8270-49ff-87e0-96520c283639"
  },
  "relationship": {
    "coding": [
      {
        "code": "self",
        "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship"
      }
    ]
  },
  "subscriberId": "8912341595",
  "id": "755a526a-0c78-4731-bac2-d6209fc30f36",
  "meta": {
    "versionId": "9999f14f-8d24-437a-8cbd-44ab8c34e7bd",
    "lastUpdated": "2024-07-01T17:02:58.689Z"
  }
}

Minimum Required Fields

While providing more data is advised for maximizing the accuracy of the eligibility response a payer can provide, there is a minimum set of fields that are required in order to receive a successful response:

Subscriber's first name
Subscriber's last name
Subscriber's member ID
Patient's first name
Patient's last name
Patient date of birth
Payer ID
Patient relationship to subscriber
Service date
Provider NPI

Note that some payers may require fields that are not in this list, consult your agreement with specific payers for more information. These are some common additional fields that payers may require:

Subscriber's date of birth
Relationship code

Sandbox

The response to an eligibility check in a sandbox Oystehr project will be a pre-defined response that will not change based on information that is sent to it. When you're ready to begin production usage, reach out to our team at [email protected].

Clearinghouse Enrollment

Provider Enrollment

The first step in clearinghouse enrollment is loading in your practice's provider information. During onboarding, provide our team with a list of your individual/group providers with this information:

NPI
Tax ID
EIN/SSN

EDI Enrollment

EDI is the Electronic Data Interchange system which allows transaction of HIPAA standard formats from provider, to clearinghouse, to payer. Eligibility, claims, and ERAs are all examples of EDI. In most cases, eligibility enrollment is fast and automatic, but in some cases there will be paperwork for your team to fill out. Provide a list of the following payer information to our team to begin EDI enrollment:

Payer name
Insurance eligibility payer ID

Additional Resources

Eligibility Check API Reference (opens in a new tab)

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The RCM Service does not yet support FHIR R5 (opens in a new tab).

RCM Professional Claim Submission